Tag Archives | Subcutaneous Tissues

Question:
We have a patient who had a severe crush injury of the left hand which led to a comminuted fracture of the left 3rd and 5th metacarpals with an intra-articular fracture of the proximal phalanx of the left index finger. The physician’s documentation indicates the following:

There was also a soft tissue defect over the left proximal interphalangeal (PIP) joint of the middle finger. After taking samples for culture, the wounds were meticulously débrided and curetted.

Bony structures were evident over the 3rd metacarpal as well as on the PIP of the middle finger where the defect was about 3-1/2 to 2-1/2 inches. The area of the dorsum of the PIP joint of the left middle finger was about ¾ inch x ¾ inch.

Debridement and irrigation was done using 6 liters of saline with the gravity Patzakis technique and 1 liter of antibiotic.

After the wound was washed, X-rays were taken to confirm the fractures though no attempt was made to reduce any fractures because of the severe contamination. A wound-VAC was planned for the dorsum of the left hand at the PIP joint of the left small finger.

Would I report 11043 and 97605 with ICD-9 682.4 and 681.00?

-North Carolina Subscriber

Answer:
The correct codes in this situation would be 11010 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and
subcutaneous tissues), 11011 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle), or 11012 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (e.g., excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and…

All closures aren’t created equal; one of the nuances of coding these procedures is knowing how to distinguish one type from another. Read on for our experts’ advice on how to assess the three closure levels and assign the best codes.

A simple repair involves primarily the dermis and epidermis. It might involve subcutaneous tissues, but not deep layers.

How do you know when a closure might involve subcutaneous layers but is still considered a simple repair? Your provider’s documentation is the key. The difference is whether the wound is closed in layers or just a single layer, experts note. The provider might decide to include the subcutaneous layer in the closure but does so by bringing the needle through the dermis into the subcutaneous and back. That results in a single-layer closure rather than closing the subcutaneous layer first and then the dermis/epidermis second in separate closure techniques.

But “simple” doesn’t mean the repair is something anyone could do. Simple repairs involve one-layer closure, which helps set them apart from a standard E/M procedure. Simple repair also includes “local anesthesia, and chemical or electrocauterization of wounds not closed,” says Dilsia Santiago, CCS, CCS-P, a coder in Reading, Pa.

For example, if your dermatologist uses adhesive strips to close a laceration, consider it an E/M service that you’ll report with the best-fitting choice from codes 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …). Most Steri-strip applications are done by nursing staff; but even if the physician applies them, they’re included in the E/M service.

If, however, your dermatologist uses sutures, staples, or tissue adhesives to close the laceration, consider it a separate procedure. Choose…

Accounting for depth is a tricky task when coding closure.
Practices interested in ethically boosting their bottom line and getting $80 or more for the same closure repair need to walk the line that separates simple from intermediate.
What Makes a Repair “Simple”?
A wound closure is a simple repair if the procedure: